深圳市2009-2012年预防接种后血小板减少性紫癜监测情况分析

目的 分析预防接种后特发性血小板减少性紫癜(Idiopathic thrombocytopaenic purpura,ITP)的发病特征,评价预防接种的安全性.方法 通过深圳市疑似预防接种异常反应(Adverse events following immunization,AEFI)监测系统,收集2009-2012年15例预防接种后ITP病例,采用描述性方法对个案调查资料进行流行病学分析.结果 接种疫苗后ITP好发于≤2岁儿童,其中＜1岁占66.67％,1～2岁占33.33％;男女性别比为1.14∶1.接种后≤1d发生2例,≥15 d发生3例,接种至发生的最短时间间隔为数小时,最长22 d.在报告预防接种后ITP病例中,涉及8种疫苗.其中乙型肝炎疫苗5例,占33.33％,发生率1.69/100万剂;其次是全细胞百日咳-白喉-破伤风联合疫苗3例,占20％,发生率为3.84/106;麻疹-风疹联合疫苗2例,占13.33％,发生率3.50/106.接种第1剂后发生的4例,占26.67％;接种第2剂后发生的5例,占33.33％.15例ITP中,最终判定为预防接种异常反应的10例,占66.67％;偶合症5例,占33.33％.2009-2012年各类疫苗预防接种后ITP报告发生率在0.25/106 ～3.84/106.结论 深圳市2009-2012年各类疫苗预防接种后ITP报告发生率低于世界卫生组织估计的预期发生率,应加强监测,并且对严重AEFI须建立规范的救治方案和补偿机制.     

T-cell-mediated cytotoxicity toward platelets in chronic idiopathic thrombocytopenic purpura

Chronic idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder that is characterized by increased platelet destruction and is believed to be autoantibody mediated. In this study, CD3+ T cells from ITP patients had increased expression of genes involved in cell-mediated cytotoxicity. In addition, cytotoxic cell-mediated lysis of autologous platelets was shown in active ITP. Our data suggest that T-cell-mediated cytotoxicity is an alternative mechanism for platelet destruction in ITP.     

Danazol in chronic idiopathic thrombocytopenic purpura resistant to corticosteroids

16 patients (11 women and 5 men) with chronic idiopathic thrombocytopenic purpura (ITP) were treated for 3-6 months with Danazol in a daily dose of 300 mg. In 6 women and 1 man an increase in blood platelet count was observed and in all but 2 patients clinical symptoms of haemorrhagic diathesis disappeared. The platelet factor 3 availability and circulating immune complexes level determined before and after 2 months therapy disclosed normalization of both tests in the majority of patients. This amelioration in immunological tests in several, but not in all patients, coincided with platelet count increase. Side-effects were negligible. The authors conclude that Danazol may be of valuable in the management of chronic refractory to corticosteroids ITP patients and that its possible mechanism of action may be an interaction with the immunologic pathways of blood platelet destruction.     

Efficacy and safety of abciximab in diabetic patients who underwent percutaneous coronary intervention with thienopyridines loading: a meta-analysis

Background

It has been controversial whether abciximab offered additional benefits for diabetic patients who underwent percutaneous coronary intervention (PCI) with thienopyridines loading.

Methods

MEDLINE, EMBASE, the Cochrane library clinical trials registry, ISI Science Citation Index, ISI Web of Knowledge and China National Knowledge Infrastructure (CNKI) were searched, supplemented with manual-screening for relevant publications. Quantitative meta-analyses were performed to assess differences between abciximab groups and controls with respect to post-PCI risk of major cardiac events (MACEs), angiographic restenosis and bleeding complications.

Results

9 trials were identified, involving 2,607 diabetic patients receiving PCI for coronary artery diseases. Among those patients who underwent elective PCI or primary PCI, pooling results showed that abciximab did not significantly reduce risks of MACEs (for elective-PCI patients: RR_1-month: 0.93, 95% CI: 0.60–1.44; RR_1-year: 0.95, 95% CI: 0.81–1.11; for primary-PCI patients: RR_1-month: 1.05, 95% CI: 0.70–1.57; RR_1-year: 0.98, 95% CI: 0.80–1.21), nor all-cause mortality, re-infarction and angiographic restenosis in either group. The only beneficial effect by abciximab appeared to be a decrease 1-year TLR (target lesion revascularization) risk in elective-PCI patients (RR1-year: 0.83, 95% CI: 0.70–0.99). Moreover, occurrence of minor bleeding complications increased in elective-PCI patients treated with abciximab (RR: 2.94, 95% CI: 1.68–5.13, P<0.001), whereas major bleedings rate was similar (RR: 0.83, 95% CI: 0.27–2.57).

Conclusions

Concomitant dosing of abciximab and thienopyridines provides no additional benefit among diabetic patients who underwent PCI; this conclusion, though, needs further confirmation in larger studies.     

Treatment of refractory chronic idiopathic thrombocytopenic purpura with high dose intravenous immunoglobulin

Three patients with a history of chronic idiopathic thrombocytopenic purpura stretching back over 20 years are reported. Despite splenectomy and immunosuppressive therapy satisfactory control of their disease has not been achieved. They had remained refractory to all therapeutic manoeuvres with corticosteroids and immunosuppressives for years with thrombocyte counts between 5,000 and 25,000/microliters and the concommitant risk of bleeding. This report describes the treatment of bleeding complications in these patients with high dose intravenous immunoglobulin; the peripheral blood thrombocyte count increased in all three patients from subnormal towards normal, but 2 to 4 weeks later returned to its initial low value. During the therapeutically induced raised thrombocyte count a normal bleeding time and only a moderate inhibition of thrombocyte adhesion and aggregation was observed resulting in reasonable haemostasis. High dose intravenous immunoglobulin is therefore a practical method for the control of bleeding complications in patients with refractory chronic idiopathic thrombocytopenic purpura. A clear explanation for its mode of action has not been found - the lymphocyte subpopulations remained unchanged and immunoglobulin production in vitro during the course of treatment was only minimally decreased.     

The impact of adjunctive eptifibatide therapy with percutaneous coronary intervention for acute myocardial infarction

The role of small molecules anti-glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti-GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST-elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n=167) to those who were not on anti GP IIb/IIIa inhibitors (n=49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub-acute stent thrombosis. Nonetheless, there was a non-significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P=0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non-significant trend towards better short-term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.     

Percutaneous coronary intervention for chronic total coronary occlusion: Do. Or do not. There is no try

Netherlands Heart Journal -     

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

Background

The results of chronic total occlusion percutaneous coronary intervention (CTO-PCI) trials are inconclusive. Therefore, we studied whether CTO-PCI leads to improvement of clinical endpoints and patient symptoms when combining all available randomised data.

Methods and results

This meta-analysis was registered in PROSPERO prior to starting. We performed a literature search and identified all randomised trials comparing CTO-PCI to optimal medical therapy alone (OMT). A total of five trials were included, comprising 1790 CTO patients, of whom 964 were randomised to PCI and 826 to OMT. The all-cause mortality was comparable between groups at 1‑year [risk ratio (RR) 1.70, 95% confidence interval (CI) 0.50–5.80, p = 0.40] and at 4‑year follow-up (RR 1.14, 95% CI 0.38–3.40, p = 0.81). There was no difference in the incidence of major adverse cardiac events (MACE) between groups at 1 year (RR 0.69, 95% CI 0.36–1.33, p = 0.27) and at 4 years (RR 0.85, 95% CI 0.60–1.22, p = 0.38). Left ventricular function and volumes at follow-up were comparable between groups. However, the PCI group had fewer target lesion revascularisations (RR 0.28, 95% CI 0.15–0.52, p < 0.001) and was more frequently free of angina at 1‑year follow-up (RR 0.65, 95% CI 0.50–0.84, p = 0.001), although the scores on the subscales of the Seattle Angina Questionnaire were comparable.

Conclusion

In conclusion, in this meta-analysis of 1790 CTO patients, CTO-PCI did not lead to an improvement in survival or in MACE as reported at long-term follow-up of up to 4 years, or to improvement of left ventricular function. However, CTO-PCI resulted in less angina and fewer target lesion revascularisations compared to OMT.

     

Megakaryocytes and thrombocytopoiesis in idiopathic thrombocytopenic purpura

In idiopathic thrombocytopenic purpura (ITP) patients with histological signs of stronger auto-antibody synthesis (spleen follicle hyperplasia) more frequently revealed megakaryocyte changes due to antibodies and less frequently thrombocyte production compensatory increased than ITP patients with signs of weaker auto-antibody synthesis (spleen follicle normoplasia). The observation suggest that insufficient and frequently lacking compensatory increase of thrombocyte production in ITP is caused by an autoallergic disturbance of megakaryocyte maturation.     

Correction to: Percutaneous coronary intervention for chronic total coronary occlusion: Do. Or do not. There is no try

Netherlands Heart Journal - A Correction to this paper has been published: https://doi.org/10.1007/s12471-020-01531-w     

Type III hyperlipoproteinemia in a patient with idiopathic hemochromatosis

Summary A 60-year-old man is reported with idiopathic hemochromatosis and type III hyperlipoproteinemia. Regular phlebotomy therapy and fenofibrate treatment favorably influenced the disorder of iron metabolism and the lipid disease. Evidence is given that both errors of metabolism are independently inherited diseases, although the symptoms of the first (idiopathic hemochromatosis) may aggravate the expression of the second (type III hyperlipoproteinemia).     

The use of adjunctive GPIIb/IIIa inhibitors in patients with unstable angina/non-Q-wave MI undergoing percutaneous coronary intervention

Glycoprotein IIb/IIIa receptor inhibitors represent a relatively new therapeutic approach in the field of antiplatelet therapy. Following the development of abciximab a number of small molecule GPIIb/IIIa inhibitors have been introduced such as tirofiban and eptifibatide. In this fast-moving field the interventional cardiologist needs a framework to guide decision-making for the individual patient. This review covers the efficacy and safety data from the clinical trials of GPIIb/IIIa inhibitors in the context of patients undergoing percutaneous coronary intervention for unstable angina/non-Q-wave myocardial infarction. There is an increasing body of evidence to support the efficacy of GPIIb/IIIa inhibitors in reducing the risk of adverse ischemic events in high and low risk patients undergoing percutaneous coronary intervention. A number of unresolved efficacy and safety issues remain, including the duration of treatment before and after intervention; whether a reduction in the heparin dose would further decrease the risk of hemorrhage without affecting the periprocedural thrombotic rate in patients undergoing PTCA with adjunctive GPIIb/IIIa inhibitors; and the cost-effectiveness of this therapy. When a thorough analysis of cost-effectiveness has been made, it will be easier to advocate the widespread use of these agents in all patients undergoing coronary intervention.     

Stress platelets in normal individuals and patients with idiopathic thrombocytopenic purpura.

To test the hypothesis that stress platelets (SPs) described by Tong et al. in rats may be a parameter of young platelets in humans, we examined and characterized SPs in normal individuals and in patients with idiopathic thrombocytopenic purpura (ITP). Our results indicated that SPs comprise about 1.2% of the circulating platelets in normal individuals and 2.6% in ITP patients. The configuration of SPs as well as of various irregular forms of circulating platelets was found to be supported by synergism of both the platelet microfilaments and microtubules. SPs showed some segmentation, the degree of which was similar in normal individuals and ITP patients, and they underwent further segmentation during in vitro incubation, mainly promoted by microtubules, so that they sometimes appeared like discoid platelets in a chain. These observations suggest a new mode of production of discoid platelets in the circulation. Thus, identification and enumeration of SPs may be useful for evaluating thrombocytopoiesis in humans.     

Characteristics of Helicobacter pylori-induced gastritis and the effect of H. pylori eradication in patients with chronic idiopathic thrombocytopenic purpura

BACKGROUND: The association between Helicobacter pylori infection and idiopathic thrombocytopenic purpura (ITP) has been reported widely. We investigated the prevalence of H. pylori infection, its virulence profile and the effectiveness of its eradication in patients with ITP. MATERIALS AND METHODS: Twenty patients with ITP, 20 with peptic ulcer (10 gastric ulcer (GU), 10 duodenal ulcer (DU)) and 20 with NUD were studied. The virulence profile of the strains was assessed by genotyping for cagA, vacA, iceA, and hpyIIIR/hrgA and by assaying for IL-8 and DNA fragmentation after incubation with AGS cells. Infected patients and two uninfected ITP patients received triple therapy and platelets were counted before and 1 month, 6 months, 1 year, and 2 years after eradication therapy. RESULTS: H. pylori infection was found in 17 ITP (85%), 20 ulcer (100%) and 13 NUD (65%) patients. Biopsies and strains were collected from five ITP, 20 ulcer and 13 NUD patients. The ITP patients had a pangastritis or corpus-predominant gastritis pattern. All H. pylori isolates, from ITP, ulcer and NUD patients, were cagA(+) and vacA s1/m1, and did not differ in levels of IL-8 induction or DNA fragmentation. Fifteen ITP (88%) and 17 ulcer (85%) patients had successful eradication of H. pylori. Ten of these 15 (67%) H. pylori-eradicated ITP patients had platelet recovery. There was no significant change in platelet count in the two ITP patients in whom eradication failed or in the two originally H. pylori-uninfected ITP patients, or in the treated ulcer patients. Age at onset of ITP was the main determinant of platelet recovery: 100% of patients diagnosed after the age of 60 recovered compared with only 22% of those diagnosed before 50. CONCLUSIONS: H. pylori-infected ITP patients have a corpus-predominant pattern of gastritis but the virulence profile of their strains does not differ from that of ulcer or NUD patients. Eradication of H. pylori infection is a good therapeutic option for some patients with chronic ITP, especially for those who develop ITP in older age.